Transcription:
Bellyaches, Bowels and Barfs

Dr. Michael Smith (Host):  What do you do when you are confronted with bellyaches, bowels and barfs? This is Pediatrics in Practice, the podcast from Children’s Mercy. I’m Dr. Mike. Let’s talk with Dr. John Rosen, he’s a Pediatric Gastroenterologist at Children’s Mercy. He’s also an Assistant Professor of Pediatrics at the University of Missouri Kansas City School of Medicine. Dr. Rosen, welcome to the show.

John Rosen, MD (Guest):  Thanks. Thanks I appreciate the opportunity to talk with you.

Host:  So, when you look at bellyaches, bowels and barfs, I mean how common is this actually, right? I mean this must be millions and millions of presentations a year, right? How common are we really talking about are these symptoms?

Dr. Rosen:  These are really common and you’re right, that basically these are the most common things that we will see in pediatric GI practices and family doctors, pediatricians, parents, teachers. They know that these are all really common. Because they deal with these on a daily basis. Really anybody you talk to, that has a child or maybe has experiences on their own realizes that these symptoms really impact our daily basis and then a fraction of those people with these symptoms end up in the GI practice where we get to see them.

Host:  How often when we are presenting with these types of symptoms, how often is it caused by a serious underlying disease process?

Dr. Rosen:  I think that’s a great question. And that’s the one that really parents and kids and their doctors want to get to the bottom of is this something I need to worry about or is this something I just need to treat to feel better. And it is very frequently a symptom that is not indicative of a serious underlying disease that’s going to cause some other problem in the future. But that doesn’t mean they aren’t serious. They cause a lot of distress, a lot of disability, missing school, missing work and so, there are certain things that we look for that signify yeah there is something underlying that maybe requires other testing. For instance if somebody is losing weight, that’s an alarm feature or a red flag saying we don’t know why they are losing weight, is it because something else is going on. Let’s figure it out.

Or in kids especially, is there blood in the stool? And we hear about this in adults and frequently people think about colon cancer. That is not what we think about in kids. In kids, that have blood in the stool, we think about constipation, did they have a big hard one that caused some irritation and bleeding. Or inflammation. Are things irritated in there? Do we need to go looking to figure out why and figure out how to treat it right?

Host:  So, weightloss for sure, maybe some blood in the stool. Any other warning signs that would make you think okay I need to take this a step further. I need to work this up a little bit more?

Dr. Rosen:  Yeah, there are. And I think less commonly seen but delay in puberty certainly something that we are aware of in kids, chronic inflammation can result in a delay in puberty. And then other symptoms that are unexplained, recurrent fevers, rashes that we don’t explain, those are less specific but certainly would make us think okay, you have GI symptoms and you have these other things you are dealing with, can we put them all together. What I would say is that severe pain or pain that causes somebody to miss school or pain that’s lasted a long time; those are actually not alarm features. Those are serious and important, we need to help get those symptoms to improve, but they aren’t indicative that something underlying is inflamed or injured. Just that the person is feeling those symptoms and they are real symptoms and they deserve maybe a different kind of evaluation and treatment.

Host:  Think about the general pediatrics when they see these symptoms so much, do you feel like sometimes maybe there are some patients who should have been worked up and are missed simply because oh it’s another kid coming in with bellyache?

Dr. Rosen:  That’s got to be really difficult because if a pediatrician or a family doctor even as the parent of a child, you hear bellyache all the time and most bellyaches are not going to cause injury. Most bellyaches don’t require a workup. But when do they need a workup? And when you are thinking about constant information flying at you, maybe even like our email boxes; we get so many emails and how do we pick out the ones that are really important and require attention and it requires a little experience. It’s hard to know. And for parents, this is really difficult. So, I think talking to your healthcare provider is a great idea. And then for primary care practitioners, yeah, talk to your specialist. There are certain things that are cues like blood in the stool, weightloss, delayed puberty where yeah, they need a little bit more workup, but the vast majority of patients have belly pain and it can be a really difficult thing to tease out.

Host:  When you are confronted with this, right, when the patient comes in whether it’s bellyache, bowels, barf, we’ll just kind of think of it generally right now. How do you approach it? What’s a good way to work this up to make sure we’re not missing those cases where there should be additional tests?

Dr. Rosen:  Yeah that’s a great question. And so my approach is really to think about those alarm features, obviously those things I go through a check list in my head are these present or not. Are they gaining weight appropriately or are they not. After that, I think about the severity and duration of their symptoms even though that’s not the end all be all, if somebody has had belly pain for two weeks and they had a febrile illness at the beginning, and they are doing okay and everybody at home was sick with the same thing; that’s less likely something that needs evaluation.

And so I think about the historical context. What else has been going on related to the symptoms. And then I think about the family history. So, certainly some people are at higher risk than others of having chronic diseases like inflammatory bowel disease and celiac disease. If somebody else in the family has a specific GI disorder, I certainly should consider that in light of my patient’s risk and so really, it’s the symptoms themselves, the clinical context, the family history and then also how much is it affecting their lives. Now somebody might have chronic abdominal pain, irritable bowel syndrome and it could really affect their lives and cause a lot of disability. But if it’s really not affecting their lives they are going to school, they are doing okay, I might be less likely in the absence of alarm features or family history to do any tests. I might just try to treat it and get them feeling better.

Host:  Let’s talk about a specific situation here. infants and vomiting. Right, I know that’s very distressful for parents, distressful for the general practitioner, really for anybody. So, maybe a nice review of what are the causes, the common causes of vomiting in infants and when do we need to treat?

Dr. Rosen:  One of the most common questions we get in our clinic is my baby is spitting up or vomiting is this a problem we need to look into? What do I do about it? Most infants and most vomiting will be categorized as what’s called physiologic reflux or stuff is coming up but it’s part of normal development. So, if a baby is growing well, and there’s very specific guidelines for growth especially in infancy and they are spitting up all day long, but they are also eating and happy; then no evaluation is needed. We know that this physiologic reflux can be distressing to parents or cousins or siblings, can see it all the time. But if they are growing and generally doing well otherwise, then we expect it to get worse between about four to six or seven months of age and then as they are sitting up more as they are eating more solid food, as they are getting older and their physiologic processes are evolving; we expect it to get better between nine and twelve months of age.

So really, it’s a wait it out situation. Other types of vomiting might present in different ways. So, if you have a baby that doesn’t vomit at all and then they have really severe vomiting and they become pale and tired, they have an episode that lasts for a couple of hours; that’s totally different story. That’s not physiologic reflux. We think about other disorders like intestinal obstruction, malrotation of the intestine where it is kind of blocked up. We think about FPIES and we call it FPIES because the full name is food protein induced enterocolitis syndrome and so we kind of tease out based on the history whether we think it’s this really common kind of vomiting or reflux that we see or if it’s one of these other disorders.

And the only other thing I would put in there is there are other disorders that can cause vomiting in infants but GERD or gastroesophageal reflux disease or acid reflux is thought to be relatively uncommon. It used to be that all babies got put on acid suppression because maybe it was common, or we thought it was common. But in reality, very few babies have pathological or abnormal acid reflux and very few babies actually need acid suppression.

Host:  Would you Dr. Rosen prefer if a general practitioner is faces with an infant who is vomiting, and they are not eating. They are not gaining weight. They are presenting as something maybe a little more serious. Should those go right on to the specialist?

Dr. Rosen:  That’s a great question. So, it depends on the comfort level of that practitioner. If they know what food protein induced enterocolitis syndrome looks like and they are willing to treat it, then they can. It’s a symptom based diagnosis. The same for a cow’s milk protein allergy, if they say I see this all the time in my pediatric practice, I know how to switch the formula. I know what to expect or watch for over the next couple of weeks, they do not need a specialist for that. However, I would say they deal with so many different things and like you mentioned before, it’s this rapid fire I’m seeing lots of patients with lots of symptoms, I think if a primary care provider feels like they need advice or assistance or even reassurance, I think I have the answer but I just want to make sure; referral to a specialist is fine. That’s what we are here for.

Host:  So, the last question then so moving away from infants and vomiting, let’s talk about another very, very common one, right. Chronic constipation. And I think again, for a lot of general practitioners, I can handle most of these cases myself, what are the warning signs though in chronic constipation that I need to be calling someone like a Dr. Rosen?

Dr. Rosen:  I think that the warning signs can be pretty similar. If that constipation is really affecting their ability to eat or grow, if that constipation isn’t getting better with whatever treatment that primary care provider is comfortable with, which usually would be osmotic laxatives, things that kind of pull water into the poop and hopefully they’d consider stimulant laxatives which help the colon push poop through; if they have tried those things and it’s not getting better; then I think referral is very reasonable. I think that there’s a lot that people can try with diet, with dietary fiber, even though the evidence doesn’t support that as being really effective, I think a lot of people prefer that approach and it works for some and I think it’s very reasonable to do.

So, the only other warning signs with chronic constipation or reasons for referral is somebody does an exam and the anus or the hole where the poop comes out of, if it doesn’t look normal and that could be any variation, they need to see a specialist, a colorectal surgeon or a GI doctor and if there’s a family history again back to the family history of things like Hirschsprung’s Disease or other specific disorders that can run in families; then definitely referral would be indicated.

Host:  So, Dr. Rosen, in summary, what would you like people and really the general practitioner, what would you like them to know about bellyaches, bowels and barfs?

Dr. Rosen:  That’s kind of a broad field but those are the most common things that we’ll see in pediatric GI and they are welcome to refer those patients because we can help them sort things out. But I think also, it’s important for a general practitioner even a parent to know that in the absence of certain alarm features like weightloss, like blood, most of those disorders are very treatable and don’t need extra tests. I think knowing how to navigate that can be difficult but certainly the healthcare provider and the family and the patient working on it together on an ongoing basis is needed, it’s necessary.

Host:  That’s Dr. John Rosen. He’s a Pediatric Gastroenterologist at Children’s Mercy. Thanks for checking out this episode of Pediatrics in Practice. Please visit www.childrensmercy.org, that’s www.childrensmercy.org to get connected with Dr. Rosen or another provider. If you found this podcast helpful, please share it on your social channels and be sure to check the entire podcast library for topics of interest to you. And be sure and check back soon for the next podcast.